The teaching system is structured in such a way that it eases a medical student into the process of doing a patient’s history and physical examination. The student then, although not expected to be brilliant in deducing diagnoses, is at least expected to begin to think about at least one diagnosis that can be isolated to a single major organ system.
We were first required to start with blindfolded examinations of each other; then write down what we felt to be significant findings, only then to suffer the double humiliation of the proctor not only pointing out everything we had missed, but also pointing out all our own personal physical flaws.
The first humiliation, for example, was that we all made gross assumptions that skipped important details. For example, most of the medical students did not even first state the gender of the person. This was followed by our omissions of simple facts such as the fellow student we had just examined might be wearing glasses, had a beard, or wore earrings. All of this underscored a basic tenet in medicine that one should never overlook the obvious and also that one should never assume anything.
When I began my first presentation of an examination of a fellow student, I was stopped after the first sentence.
- So, first of all, was the person a male or a female? Even blindfolded you can tell if a person has breasts, or buttocks, or a penis or not.
- Well, yes but….
- Then why didn’t you first say that the person you were examining was a female? There are many important medical issues that depend entirely upon gender you know.
- Uh, yes but…I didn’t think I should…I mean she’s a fellow student. Wouldn’t she object to being groped?
- But nothing and grope nothing. This is an objective clinical exercise, not a course in sexual harassment. So just because you might be embarrassed about this means you can sit there and tell me that someday you might miss a breast cancer? The medical examination of the breast is entirely clinical and is not the equivalent of fondling. At least it had better not be.
When I told my mother about this experience she shrugged it off as being nothing that should bother me too much. She trivialized it as she reminded me that her near-sighted brother Bobby had also learned his physical anatomy by the Braille method, albeit at night in the back seat of a car, yet never once seemed to have any problems with gender identification. She said:
- Forget the tits. That’s how your Uncle Bobby discovered that women have three holes.
The second humiliation came with the fact that all of us then had our own physical imperfections glaringly pointed out to us; dermal scars, a murmur, a curved spine, acne, a sloped shoulder, a missing pulse, an old fracture, crooked teeth, glasses, or braces; you name it. The worst part about it was that we were all only about 21 years old. By the time the proctor was through with me I thought I was should just cash it in and apply for the job of being a cadaver for the class of 1974.
It was the beginning of a lifetime dedicated to thinking morbidly of even the slightest personal ailment, a thought that unfortunately played back into my mother’s perverse tendency to always look for the worst in people. Noticing all the things wrong with someone or painting worst-case scenarios for diagnostic outcomes does not make for an optimistic outlook on life. By the same token, it does also constantly remind one that life is indeed very short. This thinking can either work beneficially by making one always try to live in the moment or it can backfire by incubating a ridiculous urge to live life to extremes.
In my case, it did not take more than a few clinical deathbeds prompts to instill a desire to do everything I wanted while I was still young. I did, in fact, try more than few risky ventures or at least stupidly attempting some of them twice; like scuba diving the 130-foot-deep Maracaibo reef in Cozumel with no prior experience, being swept out to sea into the fishing lanes while scuba diving an ocean inlet on an outgoing tide, sailing and tipping over a Hobie Cat in a full October gale without a wet suit in 60-degree water, taking psychedelic drugs; smoking hashish, trying cocaine and attempting to snow ski…for the first time. And then when I became a House Officer, attempting to screw every nurse in sight, without condoms. Damn the V.D. Full speed ahead and fire all the torpedoes.
The second phase of Physical Diagnosis comes in learning to logically format and to then scribe all the elements of a comprehensive approach to diagnosis; Age, Gender identification, Vocation (or not), Chief complaint, Past Significant Medical History, History of Present Illness, List of Medications, Social History, Family History, Surgical History, Allergies, Review of Systems, Physical Examination, Differential Diagnosis, Plan for Diagnostic Testing, and Therapy.
Then one must write a set of Orders to be carried out the actual implementation of the Diagnostic preposition and Care Plan.
At the end of this process I realized I had watched too many doctor shows on television because this was nothing at all like the relatively easy, carefree approach to medicine enjoyed by the likes of Dr. Kildare. It was also not even close to the equally irrelevant focus the actors had on each other, but not on their patients, in the complicated soap opera lives enjoyed by the likes of the cast on General Hospital. These people spent all their time perusing sex when they weren’t screwing over all their other friends or relatives physically, emotionally or financially; but somehow never seemed to get down to the real business at hand: like taking vital signs and emptying bedpans.
- Doctor. Your patient in Room 3 has a fever.
- What was the exact temperature, nurse?
- I don’t know doctor. But not as high as the hots I have for you.
Nothing at all like that, this new aspect of Medical School, being very difficult, was the first time I doubted my vocation. Unfortunately, it would only be the first of many self-doubting or soul-searching episodes as little did I know how bad things could ultimately be or how humiliating things were about to become.
First, when doing any clinical rotations, the student is expected to wear a shirt and tie, put on a short white jacket that designates the inferior rank of neophyte, as opposed to the long white coat that comes only when rising to the rank of an Attending Physician. One also then must carry around about twenty pounds of ancillary tools in a little black bag, or in the coat pockets of the white jacket, including a stethoscope, ophthalmoscope, reflex hammers, tuning forks, note pads, pens, calipers, EKG rulers and of course the Little Red Book.
I felt like a G.I. going off to battle or as uncomfortable as I was at any time I ever had to put on a tuxedo.
If I had ever thought a Cub Scout uniform was bad, having to dress like a cross between a Bus Boy and a Good Humor Man was nauseatingly stilted and made me feel as though I would be infinitely better off instead standing stiff legged still in front of a drill Sergeant. with a little round wooden dowel shoved up my rear end. Cinch tied like a wild bucking bronco under his first heavy saddle; and saddened by the reality of having to ditch my soft comfortable hippie togs for a suit that made me look like a fumigator, off I trudged to the hallowed halls of the hospital wards.
My first real test in clinical medicine was being rotated to a hospital to examine a patient with liver failure, after which I wrote up the findings per protocol and then presented the case to a proctor in front of a group of five other students. I thought I had done a pretty good job. The proctor however, did not. My paper was a monument to how much red ink can actually be held in a ballpoint cartridge and how close a graded paper can come to being a Jackson Pollock masterpiece. I had missed just about everything pertinent: spider angiomas, everted navel, ascitic fluid, liver size in centimeters, rhinophyma, etc.
Then to make matters worse, when I attempted a verbal defense in front of my fellow students, the proctor jumped down my throat like that drill Sergeant would have done anyway, as he proceeded to rip me a brand-new asshole. If I ever did have that little plug up my butt, this was when it would have hit the ground with a hollow empty thud as my knees turned to jelly and sphincter tone suddenly failed.
- Do you know who I am? Do you know who I am? You don’t even know who I am, do you? Well let me tell you, then. I am Dr. Frank Iber, and I am a full Professor of Medicine at Tufts University Medical School. So, when I speak or when I critique; you will remain silent and do nothing but listen and learn. Your examination of that patient was a disgraceful example of incompetence. As such, we shall now proceed to go back to show both you and your fellow students how superficially incompetent your evaluation really was. And when we are all done with that, you will take your paper back home, then you will re-write it, after which you will also memorize the section in DeGowan on all the signs of liver disease for a verbal quiz, which I will administer at my personal discretion.
And so, we did. And so, I did. And so, he did.Bad enough I got the proctor with the bad temper and the inflated ego, but he also happened to be a national expert in Gastrointestinal Diseases who also wrote the textbook section on “The Liver.” I guess then this rotation was both the bait and the trap, eh?
It was stupid of me to have been mollified into assuming everyone was like the jocular, philosophical proctor who taught us all to be HIPPAYs. In retrospect, I guess that professor, with his pleasant affect and his all- forgiving non-offensive mentoring personality must have been a Psychiatrist.
To make matters worse, I really did not know who Dr. Iber was until I looked him up in the school directory, and thus learned a painful lesson about the mysterious hierarchies of the world of Medicine. Some people are, in fact, more important than others and obviously not ashamed to let you know it. Doing background research ahead of time, if nothing else, could have at least ensured me a few ingratiating brownie points.
I was hurt, humiliated, embarrassed, demoralized, angry, and ready to quit school. However, Michael propped up my badly bruised ego, having encouraged me by the reassurance that everyone goes through it, and that after the first time it can only get better.
It was just another game that had its own set of rules, with a peculiar set of standards that had to be learned; such as the correct timing for self effacing groveling or the tossing of dust on and over ones bowed, scraping head. Once you know the rules, it becomes infinitely easier to play the game. I was not so sure, but then again, the alternative would have been meeting a real U.S. Army Drill Sergeant and having to trade in my Little Red Book for a Big Brown Duffle Bag along with a one-way ticket to Southeast Asia.
It did take a while, but I got over it and I did improve.
My roommate Michael. said it was just like learning to drive. Scary at first, and you might hopefully have only a few minor accidents, or get a few tickets, but after you get the hang of it and learn to play the game, it’s just as easy as learning anything else. But to me the length and breadth of medical knowledge seemed as insurmountable as a successful climb to the peak of Mount Everest; even with the added benefit of having some extra oxygen canisters on board.
Michael also helped with the proactive part of things by proceeding thereafter to point out the best clinical rotations to take in the third year of school as well as the pitfalls of each one, the peculiarities of the proctors, the nice ones, the mean-spirited ones along with all the important signs, symptoms, facts, or trick questions to anticipate as each one came along.
When you come to think of it, the scary thing is that in just over twenty-two months of clinical training, the Medical student goes from the floundering, blubbering naive state I found myself under the hawkish scrutiny of Dr. Iber, to becoming an Intern in a hospital where he or she has the responsibility of making decisions that can mean the difference between life or death. Because Internships begin in the summer, there is an insider’s facetious mantra in all the academic medical training programs that is unknown and secreted from the general public..
“Just don’t ever get sick in July”
The failsafe here is that the rigid pecking order ensures constant supervision at every level. The Attending supervises the Fellows and the Residents; then the Fellows and the Residents supervise the Interns. But Interns will always at times find themselves in situations in which the decision to be made must be expeditious and solely his own responsibility. That is when the “Yell for help” becomes the credo of not only the real neophyte; but also of everyone else in the teaching hierarchy.
Then the more he is exposed to disease, dilemmas and disasters, the better trained the physician becomes as he slowly rises to the top of the medical food chain and finally gets to wear that long white coat: Full Attending Physician or Professor of Medicine.
One thing I came to learn for sure was that there is no shame in admitting “I just don’t know” because in Medicine when pride supersedes humility the unintended consequences might be permanent harm or even death. No one in medicine knows everything. But everyone does know something. And just as is it at the highest levels of any professional performance, there is always someone who is better at something than anyone else is. Even Tiger Woods could lose and eventually every icon becomes old, tarnished or simply out of date. Just ask Jack Nicklaus what he thinks about that.
At least I got the drift that when finally getting to the top of this academic world, I could still reserve the right to be somewhat nice or pleasant about it; and also learned that compassionate constructive criticism was probably a better way to teach a subordinate than abject self-promoting narcissism.
Ask and it shall be given unto you
Seek and you shall find
There is assurance of salvation
And blessings when you knock
(The Bible. Hebrews 11:6)